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Individual

CLARK B WYSONG

Active
Sole proprietor
No

Provider details

NPI number
Gender
Man
Credential
MD

Contact information

Practice address
19875 N 51ST AVE, GLENDALE, AZ 85308-5114
(623) 581-8998
(623) 581-6461
Mailing address
19875 N 51ST AVE, GLENDALE, AZ 85308-5114
(623) 581-8998
(623) 581-6461

Taxonomy

Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
25168
AZ

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
385527
AZ
Enumeration date
03/06/2006
Last updated
01/10/2013
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